1487710588 NPI number — LETHA CAMPBELL M.ED., CCC-SLP

Table of content: ELVIRA REYES ITDS (NPI 1073611984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487710588 NPI number — LETHA CAMPBELL M.ED., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPBELL
Provider First Name:
LETHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOENIGHAUS
Provider Other First Name:
LETHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.ED., CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487710588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5016 GRIST MILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VILLA RICA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30180-5401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-783-9498
Provider Business Mailing Address Fax Number:
877-977-9552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5016 GRIST MILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VILLA RICA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30180-5401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-783-9498
Provider Business Practice Location Address Fax Number:
877-977-9552
Provider Enumeration Date:
12/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP006046 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 571152749 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 571152749 . This is a "TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 786634130A . This is a "PEACHSTATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 571152749 . This is a "COVENTRY" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 571152749 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 100842 . This is a "TRADING PARTNER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 786634130A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 867779344A . This is a "PAYEE ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 786634130F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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